Category: Medisoft

Medisoft v24
ICD-10medical billingMedical Billing and CodingMedisoftpatient payments

New Medisoft V24 Features

New Medisoft Version 24 Features

Medisoft released version 24 with several key new features. Among the new features is Transaction Entry Alerts. With alerts, you can create rules that notify billers of potential issues before sending a claim. Another new feature is enhanced eligibility response displays, which display distinct and expandable sections on a patient’s insurance eligibility, allowing for easier comprehension of eligibility status. Additionally, eMDs enhanced Medisoft’s mobile app with more information and better scheduling features.

Let’s take a quick look at each of these items.

Transaction Entry Alerts!

Is your billing department a one-person show trying to keep track of all the rules of billing your claims correctly? Do you have billing staff taking vacations and wanting to leave pages of notes for the person filling in while they are away? Or maybe you employ multiple billers working on your data simultaneously and need to enforce billing claims rules correctly the first time? Regardless of your billing situation, Transaction Entry Alerts may be a solution to creating cleaner claims during the entry process!

This new feature to Medisoft version 24 allows you to create rules based on many different criteria. Alert messages are displayed when saving transactions while you are still in the transaction entry screen. With these alerts, staff can resolve any issues before creating claims!

Below is an example of a simple alert that could easily shorten the processing time by days or even weeks if caught early in the process. The rule states that for a specific insurance company (MED03), when a data entry person enters a specific code (in this case, 99397), an alert appears within the Transaction Entry screen, notifying the user that the code is invalid. Furthermore, the message directs the user of the appropriate codes to use for Medicare (G0439 or G0438)

So, taking a few minutes to create an alert could save your company thousands of dollars or many hours working rejected or denied claims.

 Transaction Entry Alerts are one of the latest features added to Medisoft that allows you to take more control of your claim processing by ensuring your payers are getting the right information the first time a claim is submitted.

If you have a billing service or run multiple data sets within your practices, you can copy alerts created in one practice to any other practice, saving you time. We encourage you to check out transaction entry alerts. It may be the best thing you can do for yourself and your business.

Enhanced Eligibility Response Displays

This feature requires using a clearinghouse designed to integrate with Medisoft. Sunrise Services offers this through our clearinghouse partners at Change Healthcare. We recommend bundling electronic claims, insurance remittance posting, and eligibility services together. If you are already using and happy with a different clearinghouse, it may be possible to set up eligibility only through Change Healthcare, so you can use this new feature while maintaining your existing claims clearinghouse.

Eligibility displays are more readable and useful

With version 24, eligibility displays are more readable and useful.  They include expanding sections for better access to information. Here’s a screenshot from the new eligibility response display. Notice the different data sections, and you can click on a specific section to expand it and see more details. Version 24 provides a smoother workflow for your front-office staff to manage and find deductible amounts, coverages, and more.

General information appears in the header, as seen in the graphic below. Notice the green checkmark? It indicates that the patient has an active insurance health plan coverage.

Receive more detailed information in the sections below the header. Expand or collapse each section by clicking on the little arrow left of the section’s name. If the arrow points right, toward the section name, clicking the arrow expands that section, providing more details specific to that section. Expanding the section is called “drilling down” to see more information.

If the arrow points down, then clicking it collapses the section, and the detailed information becomes hidden from view. Drilling down into only the sections from which you want information makes for a cleaner and quicker query.

The example below shows an expanded deductibles section with the status of deductibles for both the individual and family. Please note that the information you receive is limited to what the insurance company releases through the clearinghouse.

In the below graphic, the bottom section, named Other Benefits, is a repository for other information not otherwise applicable to the other sections.

You can print the screen by clicking on the printer icon at the top left of the screen. Each section prints in its expanded or collapsed form, depending on how you are viewing the screen. For example, in printing this screen, the deductibles section includes detailed information because it’s expanded. The other sections are all collapsed and show no details on the printout. If you also wanted to print out Active Coverage details, then expand that section before printing.

You can also print a specific section by Right-clicking on that section and selecting the Print option.

Medisoft Mobile App v3.2

With Mobile App 3.2, eMDs implemented both back-end development upgrades and numerous new feature capabilities.

The patient’s middle initial is now visible on the patient card view. The middle initial also appears on the following screens: charges, patient search results, and new appointments.

The case number and its description now appear on the patient card. Which case appears depends on several factors.

  • If the patient is on the appointment list AND the appointment has a case, the information from that case appears
  • If there is an appointment, but no case was selected, then no case information appears because the entry operator could have selected a case and chose not to.
  • And finally, if there is no appointment and the patient has one or more cases, information from the case appears and is based on your Program Option settings.

eMDs added new information to the Patient Card screen as well.

You can now view Secondary and Tertiary Insurance information on the patient’s case. And for all insurances, policy and diagnosis codes from the listed case now appear on the patient card. You can also see diagnosis codes from the case and the patient’s balance views.

Medisoft features Guarantor (or family) billing. You can send one statement to an entire family that includes each member’s balance. The sum of all those balances is called the quick balance. In Medisoft, you view the quick balance by pressing F11. That balance was not previously available from the mobile app. Now, when you tap the balance on the screen, you can see the guarantor’s quick balance.

You can now select a case when creating an appointment in Medisoft Mobile. Previously, you could review existing appointments and add new appointments. Unfortunately, you could not edit, move, or delete an appointment. With version 24, you have much more control over the entire appointment entry system in Medisoft.

If you already have Medisoft version 24, you can view our online training videos at Or, check the Medisoft help menu for more details. If you do not currently use version 24 and would like to upgrade, please contact our sales department 502-538-4665 option 1 or contact

Navigating eRx in Medisoft Clinical
MedisoftElectronic Medical RecordsEMREHRelectronic patient record

Navigating eRx in Medisoft Clinical v11.2.1

Sunrise Services recently concluded Medisoft Clinical upgrades to version 11.2.1. The latest version incorporates a new ePrescribing module based on an enterprise service. One tremendous advantage of the enterprise version is the elimination of downloading, installing, and managing insurance formularies and drug interactions. Instead, Medisoft Clinical incorporates these features into the service!

NOTE:  This article is for Version 11.2.1 only. If you have not updated to version 11.2.1, please contact us so we can guide you on any requirements to upgrade

As the lead Medisoft Clinical support technician for Sunrise Services, I’ve experienced with you, first-hand, how any change in a feature can affect your workflow. Therefore, I’ve compiled some of the most common questions, issues, and confusions clients experience with the new eRx service:

When you look under the ‘RX/Medication’ tab in a patient chart, you may notice several different status codes.  You must look at the entire picture to get an understanding of what the status is for the selected prescription.

Pending – The prescription has not yet left the system. No action required unless the status changes to ‘Error’,

Queued – The order is in the system and queued up to send to Surescripts and the pharmacy.  If the RX remains queued for more than 10 minutes, contact support to investigate.

Verified – The pharmacy received the prescription and confirmed receipt with a message sent through Surescripts.

Error – The prescription did not make it to the pharmacy, resulting in an error message received from Surescripts or the pharmacy. If the error message appears to be one you can remedy, correct it yourself. Otherwise, or if in doubt, call Sunrise for support.

Completed – The Rx was put in the system for a different provider and is complete. Completed prescriptions occur when you perform a ‘Medicine Reconciliation.’ Remember to remove the medicine when it is no longer active.  Just highlight the medication and move to ‘Historical.’

Sent – You’ve received no additional information from Surescripts or the pharmacy after sending the prescription.

Let’s take a closer look at the ‘Sent’ status:

If you created a paper Rx, then it is ok to have a ‘Sent’ status. On a printed prescription, the system has no way to validate whether the pharmacy received the order, so the system marks it as “sent” to indicate completeness. 

If you made an Electronic Prescription, or eRx, and the status is stuck on ‘Sent,’ then you must investigate further. The ‘Sent’ status indicates the prescription did not make it to the pharmacy, or the pharmacy sent back a denial.  You’ll see this status typically when a refill request is filled and is older than 14 days.  When you have a refill request present on the eRx Worklist, it’s in your best interest to address it as soon as possible.

If the eRx status has a sent Status, usually after about 10 minutes, you can see any associated errors by doing the following:

  • Click on Maintenance > Setup > Prescriber Management.  The Prescriber Management window will open. 
  • Click on Message History (Bottom Right).  Insert the patient’s last name and click on Search. 
  • If the status is ‘Error,’ click on the eye icon on the right to open the raw message where you can find the denial reason. 
  • If you see no reason provided, it is more than likely that the refill request is out of the date scope for the pharmacy.  To rectify, remove the eRx from the medication list and make a new one.  You should have a new status in under 5 minutes. 

NOTICE: Any eRx refill request received in the Worklist that does not have a corresponding Medication in the current medications list will result in a pop-up box. To rectify the problem, you can match the refill request from the medication on the left to a medication in the drop-down list, OR you may deny the request and select the Proceed button. The pharmacy will receive a denial request. You may also deny the eRx now and submit a new medication.

If, after you perform these steps, you require further assistance, please call Sunrise Services Support line @ 502-538-4665.

Medisoft Clinical’s latest upgrade includes several other advancements to help in your staffs’ daily workflow.

A new Prior Auth button is available in the eRx Worklist: Click the ‘Prior Auth’ button to access the CoverMyMeds ePA Dashboard.  For more information on enrollment, contact Sunrise Services support.

When you discontinue medication and select either Adverse reaction or Allergic reaction as the discontinue reason, a new section expands to enter details about the reaction. Select the severity from the drop-down options and type or select the reaction description.

A CCDA based on selections clicked in the clinical summaries is now sent to Updox (Patient Portal). Make your selections within the Special Features section of the Configuration drop-down.

The most significant changes in the new RX process are behind the scenes.  No longer is Medisoft Clinical using the PMSI application, but rather the more stable PMSI Interoperability service. This change frees up memory and allows the program to operate at a premium level.

For additional information on Medisoft Clinical’s new features and how to incorporate them into your workflow, give Sunrise Service’s support team a call at (502) 538-4665.

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Data Backups- Are You Sure They Are Being Done?


Are you CERTAIN you are backing up your data?

Here are four examples of why you should care.

HARD DRIVES FAIL – A small pediatrician’s office asked for help with analyzing some data. The best way to assist them was to back up their database to an external drive and take it back to the office since this was before affordable remote access technology.

The office staff diligently backed up their database daily to an external drive. Except they didn’t! At some point in time, the backup location had reverted to the hard drive of the computer, the very same computer on which they store their database. A failed drive and they lose both the database files and the backup too.

A few days later, their computer’s hard drive failed. When staff went to restore their backup data, much to their surprise, the CD was empty. Fortunately for them, I still had the database backup used to help them with reports.

With no backup, an office might expect to pay thousands of dollars to a specialist to retrieve data. Upwards of 60% of businesses shut down within six months after losing data. Coincidence saved this office from much worse alternatives and scenarios.


CYBER ATTACK – A practice with electronic health records software experienced a ransomware attack in 2017. Their IT company determined an employee likely accessed a website masquerading as an ICD-10 search tool. The employee called in a panic as she witnessed files changing names and systems no longer working. The immediate action was to shut off all computers and network devices and disconnect from the Internet. The malware successfully encrypted some files on the infected computer and a shared network folder of their server.

Fortunately, they had a disaster recovery plan in place. Within minutes, the system was shut down. Their IT company wiped clean the infected computer, reinstalled the operating system, and reset the network. We reinstalled the software. The practice had both onsite and offsite backups of the server and critical files.

It took two full days to complete the process, but with everything restored to the original state, the practice resumed normal operations on the third day. Imagine if no backup existed or was outdated.

VENDOR MISCOMMUNICATION – A colleague’s client faces the worst-case scenario in our first example. The billing company’s server crashed. They thought their IT company was backing up their multiple databases; however, they were not. Instead, the IT company thought the billing company was backing up their data. Nobody was monitoring the backups.

Regardless of who’s at fault, the billing company and all their clients are scrambling to find a solution. Even if you think your office has backups under control, communicate with whoever oversees them, and verify their completion regularly.

Maybe you have scheduled daily backups on your computer. Technology can fail or change unexpectedly. An unverified scheduled backup may turn out to be no backup at all. Verify your backups regularly.

MONITORED BACKUPS REVEALED A BIG ISSUE – Monitoring your computer systems, including backups, can alleviate the likelihood of more significant issues down the road. One client, who uses our cloud-based, HIPAA-compliant backup system, also backs up their electronic health records onsite to an external hard drive. After receiving reports with errors for their cloud-based backup, I checked their server for possible issues. The backup would run but wouldn’t complete successfully without errors. A reviewed of Windows logs showed errors as well. It appeared something was wrong with their hard drive or file structure.

I immediately contacted their IT company. They determined the hard drives were failing along with their RAID system, requiring a complete reconfiguration and restore. If they hadn’t had a monitored backup, they might not have found out about the failing hardware until it was too late, and the backups may have been incomplete as well.
Hardware failures, malicious cyber-attacks, and general miscommunication each demonstrate a need to monitor and verify your backup regimen. Add natural disasters, theft, vandalism, and other occurrences, and a verified back is critical.

HIPAA regulations (§164.308) require the protection of ePHI data through the implementation of “policies and procedures for responding to an emergency or other occurrence” (7)(i) and to ”establish and implement procedures to create and maintain retrievable exact copies of electronic protected health information.” (7)(ii)(A).

Sunrise Services offers offsite backup systems to help you maintain HIPAA compliance and create a proper disaster recovery plan. Call us for details. Whether you plan your backup strategies, seek help from your IT department, or ask us for help, make sure you develop a verification policy as well.

accountingaccounts receivableICD-10medical billingMedical Billing and Coding

Medisoft V24 A/R Tracker

Are you on version 23 or 24 of Medisoft Advanced or Network Professional? Have you looked at the new AR Tracker yet? If you answered “No” to either question, keep reading.

A new feature added in version 22, the “AR Tracker” module deserves an award. It is a very flexible tool that can save you time and much money by getting better control over your Accounts Receivable. It doesn’t matter if it’s just you or a staff of 20. The AR Tracker can help keep your AR efforts under control and more focused.

Do I have your attention yet? Many of you have a system of reports, notes, Final Draft messages, and color codes to help in your efforts already. You don’t have to change the way you do everything! However, you may find many of your AR efforts obsolete in a matter of minutes!

Accessible from the Activities drop-down menu, the AR Tracker pulls much of the critical information you need into one location, tying together AR management into one cohesive workflow, with advanced filtering to track and collect Insurance and patient balances.

Find and sort claims and statements in ways you didn’t know to wish for! Search results filter down by the provider, then insurance, the patient, and finally the claim number, where you can see any transaction color-coding, aging information, and so much more. From those results, you can create a task for a Medisoft user and track the outcomes.

“As an administrator, you can make sure that tasks are getting worked on and completed by their assigned follow-up dates.”

A simple right-click on a claim or statement will open the door to many of the tools you need to assist your AR process.

  • Add or view notes that are date stamped (so you can keep track of what has been done by you or others in your office)
  • Assign Status and Task codes then assign them to another staff member or yourself with a follow-up date (which a user can then use in the tracker to find his or her tasks to target the AR before it is lost)
  • Open and edit the insurance, patient, or claim and return right back to the AR Tracker list. Go straight to the patient’s transaction entry screen or to their case. Even check eligibility if you’re a Change Healthcare user.

If you have created a task for a Medisoft user, you can then create a filter template specifying the user and, or task code. The user then quickly opens the AR tracker and selects their templet to immediately target claims and statements they need to work on and enter follow up notes.

As an administrator, you can make sure that tasks are getting worked on and completed by their assigned follow-up dates.

Medisoft version 24 further enhances the module with a new field in the insurance carrier screen to enter the timely filling days. While editing an insurance, in the Address tab you’ll find the new Timely Filing Days field. Enter the number of days this insurance allows for a claim to successfully adjudicate. Back in the AR Tracker, you will notice a new column in the Details grid for claims: Days to File Pri. This column shows you the number of days before this claim reaches the timely filing deadline for that insurance carrier when it is the Primary insurance.

And it’s not just your billers that will benefit from the AR Tracker. Your front desk person using office hours can benefit from seeing Patient AR Status codes while scheduling or checking in patients. Data entry persons can get Pop-up messages when entering charges based on the same codes.

MDSuiteMedisoftRevenue Cycle ManagementValue Based Care

Vaping: How Are We Supposed to Code This?


At the time this article was written, eight people had lost their lives due to severe respiratory illness from the use of e-cigarettes, also known as “vaping.”  That number is expected by healthcare professionals to rise as this trendy alternative to cigarettes becomes more and more popular, especially in the younger population. According to the Center for Disease Control and Prevention (CDC), as of early September, there are over 450 possible cases of e-cigarette related lung illness. With this recrudescence spreading and becoming a common issue, the fact that there is no specific ICD-10 code for this diagnosis is problematic.

In March of 2017, and again in September of 2018, the American Thoracic Society (ATS) requested specific ICD-10 codes for e-cigarettes. They stated:

The development and marketing of e-cigarettes, e-cigars and other electronic nicotine delivery devices poses significant challenges to health care providers, researchers, patients, public health officials and for ICD-10-CM coding. Currently, there is no effective way for health care providers to specifically code patients who use ENDS [electronic nicotine delivery systems] products. Given the growth in its usage, both domestically and internationally, the lack of a unique code set for these products will pose a barrier for the effective use of ICD-10-CM for health surveillance and research purposes. (1)

United States. Center for Disease Control and Prevention. Coordination and Maintenance Committee. “ICD-10 Coordination and Maintenance Committee Meeting.” Page 31. National Center for Health Statistics. March 2017. Web. 30 September 2019.

No one in the healthcare community doubts the harm that vaping can cause, especially in young people. However, when documenting a patient’s diagnosis, the available ICD-10 codes do not cover e-cigarettes specifically. The ICD-10 codes one would use are F17.200 – F17.291, which indicates nicotine dependence, either unspecified, cigarettes, chewing tobacco, or other tobacco product (like snuff), and either uncomplicated or in remission. None of these would accurately describe e-cigarettes as these vaping products affect the respiratory system in a different way than cigarettes, chewing tobacco, and other tobacco products.

E-cigarettes deliver a vaporized dose of nicotine, along with various chemicals, including, but not limited to, glycerin, propylene glycol, and flavorings. When someone vapes, they inhale vapor instead of smoke. No long-term studies exist to back up claims that inhaling vapor is less harmful than traditional smoke. Cancer takes years to develop, so it’s unclear if a product causes or increases the risk of cancer until that product has been out for at least 15-20 years. We know little about the long-term health effects of vaping.

The FDA Commissioner announced in the fall of 2018 that middle and high school students using e-cigarettes and vaping had reached epidemic proportions. This issue has only grown since then, but the codes for nicotine dependence haven’t changed since they were new codes in 2015. The new ICD-10 codes for 2020, which set for release by the time this article runs, do not include any alterations to the nicotine dependence codes, specifying e-cigarettes, nor are there new codes for this wide-spread, still growing health issue. It seems like we will be waiting another year to accurately document and survey the prevalence of developing respiratory issues caused by this possibly deadly trend.

If you need more information or assistance from trained coders and billers, contact us to purchase an “Ask Us Anything” support contract, and we will be happy to help.
EHREMRIntegrated Cloud Based SolutionsMedisoftPatient Generated Health Data

Defining Patient Generated Health Data

apple watch

We’ve all seen the ads for the new Apple Watch were a user can generate an EKG and possibly see anomalies in heart rhythm.  This is just one example of how new technology opens up a world in which generating data can come from any personal device.

The Office of the National Coordinator for Health Information Technology (ONC) defines patient generated health data (PGHD) as health-related data created and recorded by or from patients outside of the clinical setting to help address a health concern. To date, patient health information, such as activity level, biometric data, symptoms, medication effects, and patient preferences, has been predominantly collected by members of the care team in a clinical setting or through clinical in-home devices for remote monitoring.

The proliferation of consumer health technologies, such as online questionnaires, mobile applications (apps), and wearable devices, has increased the frequency, amount,
and types of PGHD available. These advances can enable patients and their caregivers to independently and seamlessly capture and share their health data electronically with clinicians and researchers from any location.

One of the challenges PGHD faces is patients not understanding the advantages of capturing and sharing PGHD with clinicians and researchers.  Lack of access to PGHD technologies (we all can’t afford a new Apple Watch every year), varying levels of health and technology literacy and patient concerns about data privacy and security may prevent patients from participating.

Recently, both Aetna and United Healthcare started initiatives on either low cost or free devices to members.  United Healthcare enrollee’s have the ability to “walk-off” the cost of the device over a six-month period, while Aetna and Apple have been in discussions to bring the Apple watch to it’s members.

Another challenge comes with the accuracy of consumer health devices.  The quality of data captured using FDA-approved home health monitoring devices meets specified levels of accuracy. However, there is less clarity about the accuracy of general wellness devices that are not subject to FDA approval.  A 2016 study reported some popular wearables are consistently inaccurate at measuring energy expenditure, such as calories burned, when compared to gold-standard measurements, such as metabolic chambers, which are control rooms where a person can reside for a period of time while metabolic rate is measured during meals, sleep, and light activities.  Additionally, user authenticity is a concern as the risk of stolen device could result in a stolen identity or sharing of the device could result in inaccurate readings.

A look forward anticipates that digital health technologies will become more pervasive, offering more opportunities for patients to capture, use, and share their PGHD in support of health care delivery and research. The capture of PGHD alone is not sufficient to cause change within the health IT ecosystem. Joint action from across the ecosystem is necessary to overcome cultural, technical, and regulatory barriers. However, through collaboration, these barriers can be addressed, resulting in improved insights for clinicians and researchers and improved care for patients.


New Patient Image
MDSuitemedical billingMedical Billing and CodingMedisoft

What Makes A New Patient “New”?

A patient makes an appointment at your clinic and “has never been seen before”, you bill a new patient visit only to have the payer reject the claim, stating, “New patient qualifications have not been met”.

So, what went wrong?  Not all Evaluation and Management (E/M) codes fall under the new (versus established) categories.  For example, if the patient presents through the Emergency Department, the patient is always new, and the provider is always expected to get the patient’s history to diagnose a problem.  However, in the office setting, the patient sees their primary provider routinely.  The provider knows- or can quickly access- the patient’s history to manage their chronic conditions, as well as make decisions on recent problems.

The definition of a new patient in the CPT code book is: “one who has not received any professional services from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.”  In addition to this definition, CMS adds “an interpretation of a diagnostic test, reading an X-ray or EKG etc., in the absence of an E/M service or other face to face service with the patient does not affect the designation of a new patient.”[i]

Three key components that make up a new patient are:

  1. Professional Service (not modifier 26)– If the provider has never seen the patient face to face, a new patient code should be billed.
  2. Three-year rule- the general rule to determine if a patient is “new” is to check to see if that patient has been seen in the past three years. Check your dates on this-if the patient was seen the last time in May of 2015 and its March of 2018, it hasn’t been three years, according to the payer.
  3. Different specialty/subspecialty within the same group is possibly the most confusing. For Medicare patients, use the NPI registry to see what specialty the physician’s taxonomy is registered under.  The credentialing process is of upmost importance in ensuring no denials happen due to improper credentialing.

What happens when doctors switch practices?

If a doctor changes practices and takes his patients with him, the provider cannot bill for the patient as a new patient based on the “new” tax ID.  The tax ID doesn’t matter because the provider has already seen these patients and has established a history.  Just because the patient is being seen in a new facility, that patient is still seeing the same provider.

What happens when a provider sends the patient to mid-level provider?

When an MD or DO sends a patient to a mid-level provider (Nurse Practitioner or Physicians Assistant) and the visit is not an incident-to, the mid-level provider could bill a new patient code if they are a different specialty with different taxonomy codes.  An example would be a family practitioner and the mid-level sees hematology patients.  Since the specialty is different, the mid-level could bill as a new patient visit.  However, if the mid-level is also considered family practice, then a new patient visit code could not be used.

Of course, in billing there are always exceptions to the rules.

For example:

  • For some Medicaid plans, obstetric providers need to bill an initial prenatal visit with a new patient code, even if they have seen the patient for years prior to the patient’s pregnancy. Make sure you check your own local rules and Medicaid plans if you are billing obstetrics.
  • Hospitalists and Internal Medicine providers are the same specialty according to Medicare, even though each has a different taxonomy code.

If a new patient claim is denied, look to the medical record to see if the patient has been seen in the past three years by your group.  If so, check to see if the patient was seen by the same provider or a provider of the same specialty by checking the NPI registry website.  It’s always helpful to know how the provider is registered with the payer denying the claim.  If in researching all of this, there isn’t any substantiating evidence to support the denial, appeal the claim.


[i] Medicare Claims processing manual, chapter 12-Physican/Nonphysician Practitioners (30.6.7)


Modifications to MIPS by the “Bipartisan Budget Act of 2018”

The Further Extension of Continuing Appropriations Act, 2018 (HR1892) (officially renamed the “Bipartisan Budget Act of 2018”) enacted by the United States Congress and President Trump on February 9, 2018 extends the transition years for MIPS to include 2019, 2020 and 2021. This goes beyond the 2017 and 2018 transition years CMS allocated per the original MACRA legislation. There are also some changes included in the Act that apply to the 2018 MIPS performance year.

What Changes

  • Post-transition now begins in 2022, not 2019 and includes key requirements.
    • In 2022 the MIPS performance threshold must be the mean or median of national historical MIPS scores
    • The MIPS cost category must be weighted at 30% of the score
  • During the extended transition years of 2019 – 2021, the Health and Human Services (HHS) Secretary shall:
    • annually increase the MIPS performance threshold in a “gradual and incremental transition” towards the value mandated for 2022 (the first post-transition year),
    • set the MIPS Cost category weight to be between 10% and 30%, and
    • not factor year-to-year MIPS Cost improvement into the MIPS score for 2018 and extended transition years.
  • Beginning with the 2018 performance year, the MIPS payment adjustment percentage will be applied only to Medicare Part B “covered professional services”. That means, most prominently, no MIPS payment adjustment for Part B drugs. Hence, MIPS financial incentives and penalties in absolute dollars will be reduced somewhat by this change.
  • Similarly, beginning with the 2018 performance year, the low-volume exclusion for MIPS will now only be based on “covered professional services”, rather than items as well, such as Part B drugs. Hence, the low-volume exclusion will exclude somewhat more clinicians than before. This assumes that the dollar amount and patient count thresholds of the exclusion set by CMS remain as they are ($90k and 200 patients, respectively) in the 2018 QPP Final Rule.

What Remains the Same

  • The schedule of maximum MIPS penalties for low performance or non-participation without a MIPS exclusion does not change
    • -5% for the 2018 performance year
    • -7% for 2019
    • -9% for 2020 and beyond
  • CMS will still publicize MIPS scores, category scores, and 5-star performance ratings of quality measures. More than half-a-million clinicians’ scores will be publicly reported during 4Q 2018 for the 2017 performance year.
  • The compliance and reporting requirements for Quality, advancing care information (ACI) and improvement activities (IA) do not change, although Quality benchmarks will likely continue to rise.

Key Takeaways

  • MIPS is here to stay. This Act reinforces CMS’ position that MIPS is a catalyst to move from FFS to value-based care. It further entrenches the MIPS program.
  • Clinicians may stay in MIPS longer. Easing the ramp up of the MIPS program may result in more clinicians and organizations deciding to remain in MIPS longer rather than entering an Advanced Alternative Payment Model (APM). MIPS becomes a safer sandbox or “spring training” for clinicians to develop and practice value-based care improvement strategies before moving to more aggressive programs such as APMs.
  • CMS continues to drive continuous MIPS performance improvement. The Act requires CMS to continue to increase the MIPS performance threshold year-over-year to reach the required national mean or median by 2022. In the 2018 QPP Final Rule, CMS predicts that 74% of eligible clinicians will have scores of greater than 70 for 2018. For the 2022 performance threshold, if the historical national mean or median were to be, say, 75 points, then the average annual increase in the threshold from 2019 to 2022 would be 15 points per year, enough to encourage continuous improvement.
  • MIPS compliance and complexity persist. As the growing MIPS penalty remains, MIPS compliance will remain important. MIPS regulations and requirements will continue to be updated annually and semi-annually, making it essential for organizations stay on top of the program.
  • MIPS Cost will grow in importance. MIPS Cost remains at least at 10% until it must be 30% in 2022. This confirms CMS’ commitment to making cost performance part of MIPS.
  • MIPS public reporting is on track. As CMS projected, more than half-a-million clinicians’ 2017 MIPS scores and quality measures will continue to be publicly-reported in 2018 through the Physician Compare website or through a freely downloadable file. The reputational impacts of MIPS remain intact and are even more important as providers stay in MIPS for a longer period of time.

This article was originally published on SA Ignite.


Will your EHR stand up to the Rigors of MACRA?

 What is MACRA?

MACRA is the Medicare Access and CHIP Reauthorization Act. MACRA replaces the current Medicare reimbursement schedule with a new pay-for-performance program that’s focused on quality, value, and accountability. It was signed into law on April 16, 2015 by President Obama.RIP MU

The Centers for Medicare and Medicaid Services (CMS) stated that MACRA enacts a new payment framework that rewards health care providers for giving better care instead of more service. MACRA combines parts of the Physicians Quality Reporting System (PQRS), Value Based Modifier (VBM) and the Medicare Electronic Health Record Incentive Program (MU) into one single program called the Merit-Based Incentive Payment System or “MIPS”.

What is MIPS?

MIPS is the name of a new program that will determine Medicare payment adjustments and is an acronym for the Merit-Based Incentive Payment System. Using a composite performance score, eligible professionals (EPs) may receive a payment bonus, a payment penalty, or no payment adjustment.

The Composite Performance Score is based on four performance categories:

  • Quality
  • Resource use
  • Clinical practice improvement activities
  • Meaningful use of certified electronic health records (EHR) technology

Performance for MIPS started on January 1, 2017 and will annually measure eligible providers in four performance categories to derive a “MIPS score” (0 to 100). The MIPS score can significantly impact a provider’s Medicare reimbursement in each payment year from -9% to +27% by 2022. The four performance categories are weighted:

  • 50% for quality (PQRS/VBM)
  • 25% for Meaningful Use
  • 15% for clinical practice improvement
  • 10% for resource use

The points provided for each category will shift over time to place an increasing focus on more resource use.

MediTouch is MACRA-compliant and can support your success through the transition to the new payment model.

Our software will provide you with a MACRA-specific, real-time dashboard so that you can be aware (at any point of the reporting period) of how you’re performing in the three categories on which you will be reporting.  The new MACRA-ready functionality will also identify ways in which you can take action, per patient, to improve your score.

Three MIPS Performance Categories comprising our MACRA dashboard:

  • Quality (PQRS + VBM)
  • Advancing Care Information (Meaningful Use)
  • Clinical Practice Improvement Activities

Note: Resource Use (or Cost) will not require reporting. This will be calculated based on your claims.

Want to learn more?  Use the form below to schedule a demo or give us a call at

502-538-4665 to talk with a sales representative.


medical billingMedisoft

Can your current payment system store a card on file?

Most everyone likes the convenience of paying bills online.  It’s definitely my preference, since it seems most of the time I’m not home.  I am from the generation that is use to writing a check every month, and trying to remember to buy enough stamps, so I enjoy the convenience of going online and pay a bill with my credit card or setting up an auto payment to pull funds right from my checking account.  I like that I am emailed or sent a text of said funds have left my account-it’s just more convenient.  With my  Health Savings Account (HSA), I can also keep track of all my families medical expenses too and (again the word) conveniently pay with a debit card.

From a revenue standpoint in medical office, wouldn’t it be nice to give this convenience to your patients?  Especially for families like mine where there is college student making their own medical appointments (no way I am going to give him my debit card), or a spouse who can never remember to grab the HSA card from my wallet.

For medical practices using BillFlash,there is a way to now set up auto draft payments for patients.  There are two ways to do this-with StoredPay and with PlanPay.


With StoredPay, you’re able to make the authorized payment and email a receipt rather than just sending another bill and waiting to get paid. Securely store a payment method that you can use later as agreed with your patient.


PlanPay payments are not associated with any single bill/statement but are simply part of a plan to pay off an established liability like a car loan payment would do. Create and automate payments for payment plans/agreements you make with your patients (ex, payoff $2,400 liability by making a $100/mo. payment on the 15th of each month for 24 months).

Best thing of all-it’s easy to get started!  

Simply give us a call or email at(502) 538-4665 or

Don’t currently use BillFlash and want to learn more?  Visit our website to view product information and see a video on how BillFlash works or give us a call!